CQC report explained · a residential care home
What the CQC found at Mac Mae
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were not assured that infection prevention and control procedures were safe. They found problems with social distancing, cleaning equipment, records, risk assessments, signs and access to PPE.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Outstanding
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed in this targeted inspection.
What inspectors found, March 2021
Mac Mae was inspected but not rated; inspectors found infection-control shortfalls that were acted on immediately.
Inspectors visited the home on 9 December 2020. This was an announced, targeted inspection focused on infection prevention and control during the coronavirus outbreak.
They found that infection-control practices were not yet embedded. Social distancing was not encouraged, signs about handwashing and hygiene were missing, cleaning equipment was insufficient and records did not show that extra cleaning was taking place.
The home looked clean and had no odours. People and staff were tested regularly, laundry was handled safely, and visiting and community access guidance was followed when people tested positive for COVID-19.
The service was inspected but not rated. The manager accepted the findings and made immediate changes, but this report does not show whether those changes were sustained over time.
Testing and guidance
People and staff were tested regularly. The home followed government guidance on visiting and community access when people tested positive for COVID-19.
“When people tested positive for COVID-19, government guidance for visiting and accessing the community was being followed.” from the report
Laundry arrangements
Laundry was stored before washing and people's laundry was washed separately, reducing the risk of cross-contamination.
“However, laundry was stored safely for 72 hours before washing and people's laundry was washed separately to avoid cross contamination.” from the report
Positive atmosphere
Inspectors saw people and staff smiling and talking together during the visit.
“The atmosphere at the home was very positive.” from the report
Immediate response
The manager accepted the feedback and made changes straight away after the inspection.
“The registered manager was very open to the issues identified and implemented changes immediately” from the report
Social distancing and hygiene reminders
seriousPeople were not reminded to keep apart at the dining table. There were no visible reminders about social distancing, COVID-19 symptoms or personal hygiene.
“they were not reminded by staff to social distance and there were no signs on social distancing, symptoms of COVID-19 or good personal hygiene to act as visual reminders for people living at the service.” from the report
Cleaning equipment and records
seriousThere were too few cleaning materials and the equipment was not colour coded. Cleaning schedules did not cover all areas or clearly show that additional touch points were cleaned more often.
“There were insufficient cleaning materials in the building.” from the report
Risk assessments and PPE
seriousSome COVID-19 risk assessments were not signed or dated and were not always followed. Handwashing and PPE guidance was not displayed, and PPE was not always easy to access.
“Guidance on handwashing and wearing personal protective equipment [PPE] was not displayed.” from the report
- 01What changes were made to the cleaning equipment, including the number of mops and buckets, after the inspection?
- 02How do staff now make sure people are supported to follow social-distancing and handwashing guidance?
- 03How are cleaning schedules checked to ensure the dining room and frequently touched surfaces are included?
- 04How are COVID-19 risk assessments kept signed, dated and followed for each person?
- 05Where is PPE kept, and how do you make sure it is available before people enter the kitchen or laundry?
This was an announced, targeted inspection of infection prevention and control only; the report gives no ratings for the other four questions. This explanation was written from the published report of 3 March 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2017
Rated Good; inspectors found safe, effective and responsive care, with Outstanding caring.
The inspection was unannounced and took place on 17 October 2017. Inspectors spoke with people living at the home, relatives, staff, managers and health professionals. They also checked care records, medicines records, staff records, training, complaints and quality checks.
People were found to be safe. There were enough staff, risks were reviewed and medicines were managed safely. Staff had suitable training and support, and people were helped to make decisions, eat well and access healthcare.
The strongest area was caring. Inspectors saw warm relationships and found that staff supported people to make choices, build independence and take part in important events and activities. Care was personalised and complaints were acted on.
The overall rating remained Good, as it had been at the previous inspection in November 2015. The caring rating improved from Good to Outstanding. The other four ratings remained Good.
Kind relationships
Inspectors saw a friendly and homely atmosphere. People appeared happy and comfortable with staff.
“There was a friendly, welcoming and homely atmosphere in the service and people looked happy and content.” from the report
Choice and independence
Staff supported people to make their own decisions and develop independence, including with finances, meals and personal celebrations.
“Staff went the extra mile to ensure people's choices were respected and they understood the importance of people having independence, autonomy and living a fulfilling life.” from the report
Safe staffing and medicines
The home had enough staff to meet people's needs, including at weekends. Inspectors found safe systems for storing, administering and checking medicines.
“We looked at how medicines were stored and administered and there were safe systems in place to ensure people were protected from the risks associated with medicines.” from the report
Personalised activities
People chose activities and were supported to take part in work, holidays, community events and social opportunities.
“Minutes of meetings showed that people chose the activities they wished to do and where they wanted to go and this was arranged for the following week.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you support my relative's specific health needs, including any dietary or swallowing risks?
- 02How would you help my relative make choices and build or keep their independence?
- 03How do you plan staffing so that people can attend appointments, activities and community events?
- 04How will you make sure my relative receives and takes their medicines safely?
- 05How can my relative or our family raise a complaint, and how will we be told what was done about it?
This was a comprehensive inspection covering all five rating areas, and the report says the overall rating remained Good while the caring rating improved from Good to Outstanding. This explanation was written from the published report of 23 November 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Mac Mae
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 4 July 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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